Mr. Tony O'Brien:

I thank the members for the variety of questions. I will attempt to cover all of them by grouping some of the topics together.

Regarding the core relationship between acute and community or primary care, Deputy Kelleher asked an interesting question on whether we should let the hospitals effectively control primary care. To be honest, that is the last thing I would do. These relationships are explored in different ways in different jurisdictions. However, I believe that if we did that, which effectively would be giving hospital groups control of the health care system, we would end up with a more hospital-centric rather than a less hospital-centric care system. To look at that through the lens of the issue of alignment, there is a legitimate discussion about the alignment between those two sets of organisations. My back-stop position is that they should be kept separate. There is a big job of work to be done within hospital groups, whatever boundaries they have, around the relationship between larger and smaller hospitals and more rational use of the resources. There is a separate piece of work to be done to build strength in our community services. If they were put into one place in singular organisations, as happens in some jurisdictions at this point, it would be a retrograde step for the development of community health care services in Ireland, which are coming from a lower base of resource.

The reality is that our hospitals have had more investment and historically have had slightly stronger management processes. If they were given control over primary care, I do not believe it would benefit the long-term aspirations we have for a decisive shift towards primary care.

On the alignment of boundaries, I will tell the committee a short story. Five years ago, when I was in the special delivery unit, all hospitals and community services were organised in what were called integrated service areas, ISAs, of which there were 17. On a geographical basis, that meant that one person had responsibility for hospitals and community services. Around that time, as we were heading into the winter, with my job being to manage trolley crises, we organised meetings in every ISA. Despite the fact that there were common governance structures and processes and singular management, the first thing representatives of the special delivery unit had to do was introduce community service colleagues to hospital colleagues. The structural approach was not the solution.

I was at a lecture given by Professor Rafael Bengoa who recently led the process in Northern Ireland where they have integrated trust areas. He made the very same point. They have not provided the solution and system issues need to be addressed. I am really dealing with the potential argument that has not been made that what we should do is have singular structures that combine both hospitals and community health organisations. Something like this was tried in the past but was not successful.